One of the most poignant episodes occurred at a father-daughter high school dance when he suddenly burst into tears. He hurried out of the gym, hoping his daughter hadn’t seen anything, and called his wife from the car.
Jonathan Fellus, a neurologist who is the former director of brain injury rehabilitation at Kessler, began treating Richard Anderson a month after the accident. Over the years, he and other doctors prescribed various antidepressants and anti-seizure drugs to try to quell the crying and angry outbursts.
“Of course he’s depressed,” said Fellus, now director of rehabilitation at Meadowlands Hospital Medical Center in Secaucus, N.J. “But there came a point when he should have been better” — and he wasn’t. “Any little thing would seem to set him off.”
Increasingly, Fellus said, he became convinced that Anderson’s crying was not a result of sadness or depression. He suspected a little-understood, often overlooked disorder called pseudobulbar affect (PBA) that can accompany a severe brain injury. PBA, which is characterized by involuntary and inappropriate crying or laughing episodes, is also seen in stroke patients as well as in those with multiple sclerosis, amyotrophic lateral sclerosis (also known as Lou Gehrig’s disease) and Alzheimer’s disease.
PBA, previously known as emotional incontinence, pathological laughing and crying, and involuntary emotional expression disorder, is not new. It was first described by Charles Darwin in his groundbreaking 1872 text, “The Expression of the Emotions in Man and Animals.” Little is known about its precise cause, according to the Multiple Sclerosis Foundation.
Some researchers believe that it results from impaired chemical signaling in the brain, which disrupts the pathways that control the expression of emotion. It is estimated that about 1 million Americans show signs of the disorder.
Different from depression
Distinguishing depression from PBA can be difficult because they can coexist. But unlike depression, episodes of PBA occur suddenly and may bear little relationship to the patient’s underlying emotional state. Some people with PBA cry when they are happy; others laugh when angry.
Until recently, treatment largely consisted of antidepressants. In 2010, the Food and Drug Administration approved the first drug to treat PBA, Nuedexta, which was found to diminish episodes in patients with Lou Gehrig’s disease and MS.
Nuedexta consists of a combination of two generic medicines: dextromethorphan, a common cough supressant, and quinidine, which is used to treat an irregular heartbeat. Dextromethorphan is believed to bind to brain receptors, reducing the laughing and crying, while quinidine slows the breakdown of dextromethorphan. An earlier version of the drug was rejected in 2006 because of concern about heart problems.
Fellus said he mentioned PBA to the Andersons in 2009 and told them he thought Richard might benefit from the new drug. “I think he was the first patient I put on [it],” Fellus said. (Since then, the neurologist said, he has received about $25,000 in speaking fees from Avanir, the drug’s manufacturer.)
The results have been dramatic, the Andersons say. Within a month of starting the drug in early 2011 — seven years after he was injured — Richard’s crying episodes diminished from several times a week to twice a month.
Richard said that he now feels more in control of his emotions. “I can put a cap on it,” he said. He no longer takes antidepressants, has a volunteer job working with other brain-injury patients and has expanded his social horizons.
Rose said the drug has helped her, too. “It feels so good to regain that part of my relationship where I can lean on him a little bit,” she said. “It has definitely helped [us] regain some quality of life — and that’s a lot.”
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